Provider Demographics
NPI:1184991069
Name:HEALTHSOURCE OF ALLEN LLC
Entity type:Organization
Organization Name:HEALTHSOURCE OF ALLEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:M BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-359-1362
Mailing Address - Street 1:1546 STACY RD
Mailing Address - Street 2:STE 170
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-8726
Mailing Address - Country:US
Mailing Address - Phone:972-359-1362
Mailing Address - Fax:972-359-1376
Practice Address - Street 1:1546 STACY RD
Practice Address - Street 2:STE 170
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-8726
Practice Address - Country:US
Practice Address - Phone:972-359-1362
Practice Address - Fax:972-359-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty